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Background: Return to sport after stabilization surgery using the open Latarjet procedure remains challenging. Additional knowledge is needed about postoperative shoulder functional deficits in order to better design return-to-sport programs. Purpose: To investigate the effects of the dominance status of the operated shoulder on the shoulder functional profile recovery at 4.5 months after open Latarjet procedure. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was performed. All patients who underwent the open Latarjet procedure between December 2017 and February 2021 were eligible for the study. Functional assessment at 4.5 months after the surgery was performed using the following tests: maximal voluntary isometric contractions in glenohumeral internal and external rotation, upper-quarter Y balance test, unilateral seated shot-put test, and modified closed kinetic chain upper extremity stability test, leading to 10 outcome measures. Patients whose dominant side had undergone surgery and those whose nondominant side had undergone surgery were compared with a group of 68 healthy control participants. Results: A total of 72 patients who underwent an open Latarjet procedure on the dominant side and 61 patients who underwent open Latarjet on the nondominant side were compared with 68 healthy control athletes. In patients whose dominant shoulder had undergone surgery, significant deficits for the dominant side ( P < .001) and for the nondominant side ( P < .001) were found in 9 of 10 functional outcome measures. Among patients whose operations were on the nondominant shoulder, significant deficits for the nondominant side ( P < .001) and for the dominant side ( P < .001) were found in 9 and 5 of the 10 functional outcome measures, respectively. Conclusion: Regardless of dominance of the stabilized shoulder, persistent deficits in strength, stability, mobility, power, and stroke frequency were observed at 4.5 months postoperatively. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides. However, stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder. Registration: NCT05150379 (ClinicalTrials.gov identifier).

The definition of pseudoparalysis in shoulder is controversial. Gwschend initially described pseudoparalysis as an appearance of paralysis with severe rotator cuff tear. Later, Werner described pseudoparesis as active elevation under 90° caused by an irreparable massive cuff tear. Since these descriptions, many articles across the literature make the confusion between pseudoparesis and pseudoparalysis who differ in term of lesion and treatment options. Subsequently, this adds confusion to confusion when evaluating the results to determine the optimal therapeutic strategy. Conservative and arthroplasty options are discussed but the reverse arthroplasty appears to be the treatment of choice in a true pseudoparalyzed shoulder.

Background: The time elapsed since surgery is the primary criterion for allowing athletes to return to sport after shoulder stabilization surgery using the Latarjet procedure. The objective assessment of shoulder functional status through the return-to-sport continuum demands a scoring instrument that includes psychological and physical dimensions. This study aimed to statistically validate the Shoulder-SanTy Athletic Return To Sport (S-STARTS) score in patients who have undergone primary shoulder stabilization surgery. Hypothesis: The S-STARTS score fulfils the criteria for statistical validation for assessing return-to-sport readiness after shoulder stabilization surgery. Study Design: Diagnostic study. Level of Evidence: Level 4. Methods: Fifty patients and 50 controls completed the Shoulder Instability-Return to Sport after Injury questionnaire and performed 4 physical performance tests, from which 8 outcome measures were extracted to provide a composite score, named S-STARTS, according to a scoring procedure. The statistical validation of the S-STARTS score was based on construct validity, discriminant validity, sensitivity to change, internal consistency, reliability, agreement, and feasibility. Results: The 8 components of the S-STARTS score provided additional information (0.01 ≤ | r| ≤ 0.59). The S-STARTS score exhibited good reliability (intraclass coefficient of correlation [3,k] = 0.74), no ceiling or floor effects, and high discrimination and sensitivity to change. The S-STARTS score was significantly lower in patients than in controls (13.5 ± 3.8 points vs 16.1 ± 2.7 points, respectively; P < 0.001). A significant increase was reported between 4.5 and 6.5 months postoperatively (12.8 ± 2.3 points vs 17.2 ± 2.4 points, respectively; P < 0.001). Conclusions: The S-STARTS score meets statistical validation criteria for the assessment of shoulder functional status after shoulder stabilization surgery using the Latarjet procedure. Clinical Relevance: Using an S-STARTS score–based assessment to monitor an athlete’s progression through the return-to-sport continuum may help clinicians and strength and conditioning coaches in return-to-sport decision-making.

Background: Rapid consolidation of the bone block is paramount for the success of the Latarjet procedure. Noncannulated screws have shown satisfactory long-term bone block fusion, while cannulated screws are challenged with inferior mechanical properties and fusion rates. Purpose: To report outcomes of the Latarjet procedure using cannulated screws, notably bone block fusion and complication rates at 3 months, as well as clinical scores and return to sports at minimum 2 years postoperatively. Study Design: Case series; Level of evidence, 4. Methods: We reviewed the records of 124 consecutive patients (124 shoulders) who underwent primary Latarjet procedures using cannulated screws between 2015 and 2018. All patients underwent clinical examination at 3 months postoperatively, including range of motion and radiographs to assess graft fusion. The Walch-Duplay score, Rowe score, Subjective Shoulder Value, and visual analog scale for pain were collected at a minimum follow-up of 2 years. Results: Overall, 9 patients (7%) required reoperation: 7 (6%) had screw removal for unexplained residual pain, 1 (0.8%) had lavage for deep infection, and 1 (0.8%) had evacuation to treat a hematoma. Furthermore, 3 patients (2.4%) had recurrent instability, none of whom underwent reoperation. At 3-month follow-up, all 124 shoulders showed complete radiographic graft fusion, and at 40 ± 11 months (mean ± SD; range, 24-64 months), 88% of patients had returned to sport (109/124), the Walch-Duplay score was 86 ± 14, Rowe was 84 ± 15, Subjective Shoulder Value was 88 ± 11, and visual analog scale for pain was 1 ± 1. Conclusion: The clinical relevance of these findings is that 4.5-mm cannulated screws are safe and effective for primary Latarjet procedures and grant adequate graft healing, with low recurrence of instability and a high rate of return to sports.

Background Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation. Methods A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up. Results Nine patients (8 male, 1 female) with a mean age of 58.4 years (range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction (mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%). Conclusion In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

Background The Unilateral Seated Shot-Put Test (USSPT) consists of pushing an overweight ball as far as possible to assess upper extremity power unilaterally and bilateral symmetry. Literature however reports various body positions and upper limb pushing patterns to perform USSPT, demanding to provide additional guideline to achieve overweight ball push. This study therefore aimed at assessing the reliability and agreement of USSPT outcome measures when pushing an overweight ball in a horizontal direction. Methods Twenty-seven healthy male athletes performed two sessions, one week apart, of three unilateral pushes per upper limb using a 3-kg medicine ball, for which the distances were measured. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimum detectable change at a 95 % confidence level (MDC95 %) and coefficient of variation (CV) were assessed for the pushing distances based on one, two or three trials per side to produce two outcome measures: the pushing distance per limb and USSPT Limb Symmetry Index (LSI) when dividing pushing distance of the dominant side by that of the non-dominant side. Results The most reliable pushing distance per limb was obtained when averaging three pushing distances, normalized by body mass with the exponent 0.35. The mean USSPT LSI was 1.09 ± 0.10 for the first session and 1.08 ± 0.10 for the second session, highlighting good reliability and agreement (ICC = 0.82; SEM = 0.045; MDC95 % = 0.124; CV = 5.02 %). Conclusions When the overweight ball is pushed in a horizontal direction, averaging the distances of three trials for both the dominant and non-dominant limbs is advised to provide the most reliable USSPT distance per limb and USSPT LSI.

Glenoid bone loss in anatomic total shoulder arthroplasty (aTSA) remains a controversial and challenging clinical problem. Previous studies have shown high rates of glenoid loosening for aTSA in shoulders with retroversion, posterior bone loss, and posterior humeral head subluxation. This study is the first to present minimum 2-year follow-up data of an all-polyethylene, biconvex augmented anatomic glenoid component for correction of glenoid retroversion and posterior humeral head subluxation.This study is a multicenter, retrospective review of prospectively collected data on consecutive patients from 7 global clinical sites. All patients underwent aTSA using the biconvex posterior augmented glenoid (PAG). Inclusion criteria were preoperative computed tomographic (CT) scan, minimum 2 years since surgery, preoperative and minimum 2-year postoperative range of motion examination, and patient-reported outcome measures (PROMs). Glenoid classification, glenoid retroversion, and posterior humeral head subluxation were measured from preoperative CT and radiography and postoperative radiography. Statistical comparisons between pre- and postoperative values were performed with a paired t test.Eighty-six of 110 consecutive patients during the study period (78% follow-up) met the inclusion criteria and were included in our analysis. Mean follow-up was 35 ± 10 months, with a mean age of 68 ± 8 years (range 48-85). Range of motion statistically improved in all planes from pre- to postoperation. Mean visual analog scale score improved from 5.2 preoperation to 0.7 postoperation, Single Assessment Numeric Evaluation score from 43.2 to 89.5, Constant score from 41.8 to 76.9, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score from 49.8 to 86.7 (all P .0001). Mean glenoid retroversion improved from 19.3° to 7.4° (P .0001). Posterior subluxation improved from 69.1% to 53.5% and posterior decentering improved from 5.8% to -3.0% (P .0001). There was 1 patient with both a prosthetic joint infection and radiographic glenoid loosening that required revision. Seventy-nine of 86 patients had a Lazarus score of 0 (no radiolucency seen about peg or keel) at final follow-up.This study shows that at minimum 2-year follow-up, a posterior-augmented all-polyethylene glenoid can correct glenoid retroversion and posterior humeral head subluxation. Clinically, there was significant improvement in both range of motion and PROMs.

There are different techniques to address severe glenoid erosion during reverse shoulder arthroplasty (RSA). This study assessed the clinical and radiological outcomes of RSA with combined bony and metallic augment (BMA) glenoid reconstruction compared to bony augmentation (BA) alone. A review of patients who underwent RSA with severe glenoid bone loss requiring reconstruction from January 2017 to January 2019 was performed. Patients were divided into two groups: BMA versus BA alone. Clinical outcome measurements included two years postoperative ROM, Constant score, subjective shoulder value (SSV), and the American Shoulder and Elbow Surgeons Shoulder (ASES) score. Radiological outcomes included radiographic evidence of scapular complications and graft incorporation. The BMA group had significantly different glenoid morphology (p &lt, 0.001) and greater bone loss thickness than the BA group (16.3 ± 3.8 mm vs. 12.0 ± 0.0 mm, p = 0.020). Both groups had significantly improved ROM (anterior forward flexion and external rotation) and clinical scores (Constant, SSV and ASES scores) at 2 years. Greater improvement was observed in the BMA group in terms of anterior forward flexion (86.3° ± 27.9° vs. 43.8° ± 25.6°, p = 0.013) and Constant score (56.6 ± 10.1 vs. 38.3 ± 16.7, p = 0.021). The BA group demonstrated greater functional and clinical improvements with higher postoperative active external rotation and ASES results (active external rotation, 49.4° ± 17.0° vs. 29.4° ± 14.7°, p = 0.017, ASES, 89.1 ± 11.3 vs. 76.8 ± 11.0, p = 0.045). The combination use of bone graft and metallic augments in severe glenoid bone loss during RSA is safe and effective and can be considered in cases of severe glenoid bone loss where bone graft alone may be insufficient.

The purposes of this study were to investigate a radiographic sign found on coronal magnetic resonance imaging (MRI) sequences in subscapularis (SSC) pathology, reporting interobserver reliability data and sensitivity and specificity; and to correlate the preoperative assessment of SSC pathology with intraoperative assessment of the SSc during shoulder arthroscopy.A consecutive series of patients undergoing arthroscopic rotator cuff repair from January 2020 to December 2020 were examined. The positive diagnosis of a subscapularis tendon tear was prospectively determined and confirmed by arthroscopy. The "digitation sign" was assessed by 3 independent shoulder-trained fellows when evaluating the SSC in the coronal plane on T2-weighted images.Of the 132 patients included, 74 (56%) had SSC tendon tears confirmed during arthroscopy. Interobserver agreement for digitation sign was substantial (k= 0.640). Sensitivity for digitation sign only was 74.3%; for criteria of Adams et al. (Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy;Preoperative systematic MRI evaluation by shoulder surgeons can diagnose subscapularis lesions by using the digitation sign in the coronal plane along with Adams et al. criteria, leading to good sensitivity. This easy-to-apply sign can be helpful in the initial MRI evaluation in the coronal plane, with improved sensitivity when combined with a systematic approach.II, study of diagnostic test.

Background Shoulder arthroplasty in young patients with primary glenohumeral osteoarthritis is an area of continued controversy. Methods A retrospective multicenter study was performed for all patients aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with a minimum of 24-month follow-up. Clinical and functional outcomes, complications, and need for revision surgery were analyzed. Survivorship analysis using revision arthroplasty as an endpoint was determined. Results A total of 202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). TSA survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up. A total of 31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean follow-up of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up. TSA resulted in a significantly better range of motion, pain, subjective shoulder value, and Constant score compared with HA. Conclusion In young patients with primary glenohumeral osteoarthritis, TSA resulted in significantly better functional and subjective outcomes with no significant difference in longitudinal survivorship compared with patients treated with HA.

Background Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. Methods There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. Results At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). Conclusions The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Background Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up. Materials and methods We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views. Results Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points). Conclusions Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.

To assess the effects of (1) rugby union practice, (2) history of injury managed nonoperatively, and (3) history of injury managed operatively on shoulder functional status in male rugby union players.Cross sectional study.Clinical.86 male athletes were assigned into four groups: multisport athletes, rugby union players without shoulder problems, with history of shoulder injury managed nonoperatively and with history of shoulder injury managed operatively.SI-RSI questionnaire, maximal isometric glenohumeral internal and external rotator strength, unilateral seated shot put test, upper quarter Y balance test.Healthy players presented higher internal (p = 0.03) and external (p = 0.04) rotator strength than multisport athletes. History of shoulder injury managed nonoperatively did not impair physical abilities but limited player's psychological readiness (p 0.001). After 4.5-months, shoulder stabilization surgery impaired maximal muscle strength and upper quarter body stability and mobility (p 0.001 for all).The shoulder functional status in rugby union player presented increased glenohumeral rotator strength when compared to non-collision sport athletes. In rugby union players, psychological concerns remained in the long-term after a shoulder injury managed nonoperatively, and psychological and physical readiness seemed not be reached at 4.5 months postoperatively to respond to rugby union practice demand.

Case A 30-year-old woman with an irreparable subscapularis tear presented with persistent painful anterior instability despite several open and arthroscopic stabilization procedures. A pectoralis major tendon transfer (PMTT) was performed. The patient subsequently developed progressive glenohumeral arthritis over the next 10 years, ultimately necessitating shoulder arthroplasty. Conclusions PMTT provides valuable anterior soft-tissue reconstruction stabilization for subscapularis insufficiency in a multioperated shoulder. Ten years later, the transfer was found to be intact and managed like a native subscapularis during anatomic shoulder replacement, thus avoiding a reverse arthroplasty in a young patient.

BACKGROUND: Efforts during reverse total shoulder arthroplasty (RSA) have typically focused on maximizing ROM in elevation and external rotation and avoiding scapular notching. Improving internal rotation (IR) is often overlooked, despite its importance for functional outcomes in terms of patient self-care and hygiene. Although determinants of IR are multifactorial, it is unable to surpass limits of bony impingement of the implant. Identifying implant configurations that can reduce bony impingement in a computer model will help surgeons during preoperative planning and also direct implant design and clinical research going forward. QUESTIONS/PURPOSES: In a CT-modeling study, we asked: What reverse total shoulder arthroplasty implant position improves the range of impingement free internal rotation without compromising other motions (external rotation and extension)? METHODS: CT images stored in a deidentified teaching database from 25 consecutive patients with Walch A1 glenoids underwent three-dimensional templating for RSA. Each template used the same implant and configuration, which consisted of an onlay humeral design and a 36-mm standard glenosphere. The resulting constructs were virtually taken through ROM until bony impingement was found. Variations were made in the RSA parameters of baseplate lateralization, glenosphere size, glenosphere overhang, humeral version, and humeral neck-shaft angle. Simulated ROM was repeated after each parameter was changed individually and then again after combining multiple changes into a single configuration. The impingement-free IR was calculated and compared between groups. We also evaluated the effect on other ROM including external rotation and extension to ensure that configurations with improvements in IR were not associated with losses in other areas. RESULTS: Combining lateralization, inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion resulted in a greater improvement in internal rotation than any single parameter change did (median baseline IR: 85° [interquartile range 73° to 90°]; combined changes: 119° [IQR 113° to 121°], median difference: 37° [IQR 32° to 43°]; p < 0.001). CONCLUSION: Increased glenosphere overhang, varus neck-shaft angle, and humeral anteversion improved internal rotation in a computational model, while glenoid lateralization alone did not. Combining these techniques led to the greatest improvement in IR. CLINICAL RELEVANCE: This computer model study showed that various implant changes including inferiorization, varus neck-shaft angle, increased glenosphere size, and increased humeral anteversion can be combined to increase impingement-free IR. Surgeons can employ these currently available implant configurations to improve IR when planning and performing RSA. These findings support the need for further clinical studies validating the effect of implant configuration on resultant IR.

Scapular dyskinesia refers to altered scapular motion or position. Specifically, it may include static or dynamic medial border prominence of the scapula, inferior angle prominence and/or premature elevation of the scapular, and accelerated inferior scapular rotation while lowering the arm. It generally occurs due to muscle imbalance/weakness or as a response to shoulder injury—including glenohumeral instability. Prevalence of scapular dyskinesis is 61% in overhead athletes and 33% in non-overhead athletes. Assessment should include a detailed physical examination including scapula-specific tests: the scapular assistance test (SAT) and scapular retraction test (SRT). Investigations (imaging and nerve conduction studies) should be targeted to identify any underlying shoulder pathology that may be a cause of dyskinesis. The mainstay of treatment for scapular dyskinesis is appropriate treatment of the underlying cause, followed by a supervised physiotherapy program focusing on re-establishing normal scapular motion and stability.

Objectives: Subscapularis (SSP) tendon injuries are increasingly being diagnosed by arthroscopy. Preoperative diagnosis remains a challenge with clinical examination and magnetic resonance imaging (MRI) lacking sensitivity. The purpose of the study was to evaluate a new MRI finding in the coronal plane, the ‘Digitation Sign’. Methods: A consecutive series of 197 patients who underwent surgery for arthroscopic rotator cuff repair between January 2020 and December 2020 was reviewed. Inclusion criteria were: availability of a preoperative MRI less than 18 months old and age of more than 18 years. SSP injuries were described intraoperatively according to the Lafosse et al. and the French Arthroscopy Society classifications. Of the 197 patients, 44 had a preoperative arthroscan, 21 did not have an available DICOM file, and 1 patient had a history of repair on the side being examined. We included 132 shoulders for analysis. MRI scans were reviewed by 3 independent observers. The SSP was assessed on axial, sagittal, and coronal sections according to Adams’ criteria. The ‘Digitation Sign’ was assessed in the coronal plane on the T2 sequences. The statistical analysis determined the inter-observer agreement, and sensitivity and specificity calculations. Results: The inter-observer analysis detected substantial agreement (κ = 0.640). Of the 132 patients included, 74 (56%) had an arthroscopically confirmed SSP injury. 55 (74.3%) of the SSP injuries were correctly diagnosed by the ‘Digitation Sign’ alone, 62 (83.8%) with Adams’ criteria alone and 66 (89.2%) with a combination of both. 49 (84.5%) of the intact SSP were confirmed with the ‘Digitation Sign’ alone, 45 (77.6%) with Adams’ criteria alone and only 39 (67.2%) with a combination of both. The sensitivity of the ‘Digitation Sign’ combined with Adams’ criteria was statistically better than the sensitivity of Adams’ criteria alone (p = 0.046). The ‘Digitation Sign’ was more specific than Adams’ criteria (p = 0.014). The effectiveness of the ‘Digitation Sign’ combined with Adams’ criteria increased with the severity of the injury (grade III or IV). SSP injuries were significantly associated with biceps injuries (p Conclusion: Preoperative MRI analyzed according to a protocol that combines Adams’ criteria and the ‘Digitation Sign’ is simple, reproducible and sensitive in the diagnosis of SSP injuries. The specificity of the ‘Digitation Sign’ enables quick verification of the integrity of the subscapularis in the first reading of standard coronal sections of cuff tear analysis.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability. Methods A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction. Conclusion Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up. Level of Evidence Level V, expert opinion.

Purpose The purpose of this study was to establish consensus statements via a modified Delphi process on the Latarjet procedure, remplissage, and glenoid-bone grafting for anterior shoulder instability. Methods A consensus process on the treatment utilizing a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability. Results The technical approaches identified in the statements on the Latarjet procedure and glenoid bone-graft were that a subscapularis split approach should be utilized, and that it is unclear whether a capsular repair is routinely required. Furthermore, despite similar indications, glenoid bone-grafting may be preferred over the Latarjet in patients with bone-loss greater than can be treated with a coracoid graft, and in cases of surgeon preference, failed prior Latarjet or glenoid bone-grafting procedure, and epilepsy. In contrast, the primary indications for a remplissage procedure was either an off-track or engaging Hill-Sachs lesion without severe glenoid bone loss. Additionally, in contrast to the bone-block procedure, complications following remplissage are rare, and loss of shoulder external rotation can be minimized by performing the tenodesis via the safe-zone and not over medializing the fixation. Conclusion Overall, 89% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the prognostic factors that are important to consider in those undergoing a glenoid bone-grafting procedure including age, activity level, Hill-Sachs Lesion, extent of glenoid bone-loss, hyperlaxity, prior surgeries, and arthritic changes. Furthermore, there was unanimous agreement that it is unclear whether a capsular repair is routinely required with a glenoid bone graft, but it may be beneficial in some cases. There was no unanimous agreement on any aspect related to the Latarjet procedure or Remplissage. Level of Evidence Level V: expert opinion.

Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients.A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture.A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion.Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

This study analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature.The study group consisted of 118 cases (114 patients). There were 63 women and 51 men. Mean age at the time of arthroplasty was 68 years (range, 51-85 years). True anterior-posterior radiographs obtained postoperatively and at the final follow-up were analyzed for implant seating and the occurrence of radiolucent lines. Glenoid morphology and fatty infiltration of the rotator cuff muscles were examined using computed tomography scans. Mean follow-up was 38 months (range, 24-70 months).The mean radiolucent line score after surgery was 0.54 points (range, 0-3 points), and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points), and 74% had no or only 1 radiolucent line. The score increased significantly over time (P .001). No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines.In the short-term, the glenoid component analyzed in this study showed promising radiographic results, with a low number of radiolucent lines without failure. However, the mean radiolucent line score increased significantly over time, and long-term observations are necessary to confirm a possible advantage compared with older component designs.

Objectives To assess the reliability of a modified procedure for Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST). Design Intra- and intersession reliability and agreement; Setting Clinical. Participants Twenty-seven asymptomatic athletes. Main outcome measures The modifications (m-CKCUEST) in CKCUEST procedure consisted in hand spacing at one half arm-span, and to complete the three regular-series of 15 s exertion by performing a fourth 1-min series during which the number of touches was counted every 15 s. The intra- and intersession reliability and agreement were assessed for the numbers of touches in order to produce two outcome measures: m-CKCUEST score and muscular endurance index. Results The most reliable m-CKCUEST score was obtained when averaging the numbers of touches of the second and third sets (Intraclass Coefficient of Correlation(3,k); ICC = 0.92). Good reliability was found for muscular endurance index computed when dividing the one-half number of touches counted during the last 30 s of 1-min set, by the m-CKCUEST score calculated above (ICC = 0.86). Conclusions The m-CKCUEST allowed the production of two reliable outcome measures, which assessed the upper limb stability and the muscular endurance. Such outcomes may be used in a follow-up to assess performance or rehabilitation level.

© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees Background: The Walch classification describes glenoid morphology in primary arthritis. As knowledge grows, several modifications to the classification have been proposed. The type D, a recent modification, was defined as an anteverted glenoid with or without anterior subluxation. Literature on the anteverted glenoid in primary osteoarthritis is limited. The purpose of this study, therefore, was to analyze the anatomic characteristics of the type D glenoid on radiographs and computed tomography (CT). Methods: The shoulder arthroplasty databases from 3 institutions were examined to identify patients with primary glenohumeral osteoarthritis and glenoid anteversion (≥5°), with or without anterior subluxation. The type D study cohort consisted of 18 patients (3% of the osteoarthritis cohort) and was a mean of 70 years old, with 11 women and 7 men. All radiographs were reviewed, and computed tomography Digital Imaging and Communications in Medicine (National Electrical Manufacturers Association, Rosslyn, VA, USA) data were analyzed on validated 3-dimensional imaging software. Rotator cuff fatty infiltration, glenoid measurements (anteversion and inclination), and humeral head subluxation according to the scapular plane were determined. Results: In the study cohort, the mean glenoid anteversion was 12° (range, 5°-24°), the mean inclination was 0°, and the mean anterior subluxation was 38% (range, 6%-56%). Eight patients (44%) had a biconcave glenoid with a posterosuperiorly positioned paleoglenoid and an anteroinferiorly positioned neoglenoid, and 10 patients had a monoconcave glenoid. Fatty infiltration of the rotator cuff muscles never exceeded Goutallier stage 2. Conclusion: The type D glenoid is an addition to the original Walch classification and is characterized by glenoid anteversion (≥5°), anteroinferior humeral head subluxation, and absence of severe subscapularis fatty infiltration.

Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.

Introduction Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged Methods Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. Results The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. Conclusions The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.

Resume Introduction Actuellement, la radiographie standard de face et le profil de Bernageau sont les principaux outils d’evaluation du positionnement et de la consolidation des butees pre-glenoidiennes utilisees dans la litterature. Objectif A l’aide d’une etude radiographique cadaverique, l’objectif de ce travail etait de determiner si ces incidences radiographiques etaient fiables et reproductibles pour l’evaluation du positionnement d’une butee pre-glenoidienne et des vis de fixation. Methode Une scapula isolee, sans antecedents particuliers, sans arthrose a ete utilisee pour l’etude. Une butee pre-glenoidienne a ete realisee et osteosynthesee par 2 vis malleolaires legerement divergentes et de taille differentes pour pouvoir les identifier. Un scanner a ete realise pour servir de base a l’analyse. Puis la scapula a ete positionnee sous controle scopique afin de realiser une face stricte et un profil de Bernageau strict. A partir de cette position 0, une radiographie a ete realisee en variant l’angle de 5° – 10° – 15° dans tous les plans de l’espace. Les cliches ont ete realises lors de la meme seance pour ne pas modifier la distance tube-scapula puis exportes vers Osirx pour l’analyse. Nous avons mesure : l’angle des vis par rapport a la surface glenoidienne, ainsi que la position de la butee et son debord. Enfin, en utilisant des espaceurs calibres a 1 mm, nous avons evalue le contact osseux ou son absence. Resultats Nous n’avons retrouve aucune correlation entre la mesure scanner de l’angle des vis et celles mesurees sur la radiographie (face et profil). Il en est de meme pour ce qui est de l’analyse du debord osseux. Un espace d’1 mm ou moins entre le col de la glene et la coracoide ne peut pas etre visualise en fonction du positionnement du sujet. Conclusion La radiographie standard ne permet pas une analyse fine du positionnement de la butee et du contact osseux. Seul le scanner permet d’analyser la position de la butee, des vis et le contact osseux. Niveau de preuve Etude fondamentale.

Resume Introduction Dans l’instabilite chronique de l’epaule, l’intervention de Latarjet permet une stabilisation efficace. Cette intervention concerne majoritairement une population jeune et sportive. L’impact fonctionnel est donc majeur. Les donnees de la litterature ne permettent pas de conclure du delai precis de la recuperation de la fonction, professionnelle ou sportive. La realisation de cette intervention sous arthroscopie pourrait avoir un benefice sur la recuperation fonctionnelle. Nous avons mene une etude prospective, multicentrique, comparant la recuperation fonctionnelle apres intervention de Latarjet a ciel ouvert et sous arthroscopie. Materiel et methode Entre juin 2014 et novembre 2014, nous avons mene une etude prospective multicentrique, incluant 184 patients. Quatre-vingt-cinq patients faisant partie du groupe ciel ouvert, 99 du groupe arthroscopie. Les patients ont ete evalues en preoperatoire a l’aide du score de fonction de WOSI. La douleur postoperatoire immediate a ete evaluee a j3, j7 et j30. Le WOSI postoperatoire a ete evalue a 1, 3, 6 mois et 1 an de suivi. Resultats Les scores fonctionnels de l’epaule des deux populations etaient globalement identiques en preoperatoire. En postoperatoire immediat, la douleur etait statistiquement moins importante a j3 et j7 en faveur du groupe arthroscopie. Le WOSI postoperatoire etait ameliore dans les 2 groupes des le troisieme mois, avec une evolution sur une diminution progressive sur 1 an. Au troisieme mois, le score de WOSI etait plus favorable pour l’arthroscopie alors qu’au sixieme mois, le score de WOSI etait plus favorable pour le ciel ouvert. Conclusion Cette etude montre que la technique arthroscopique genere moins de douleur pour la periode postoperatoire immediate. L’intervention de Latarjet, sous arthroscopie ou a ciel ouvert, ameliore le score de fonction de l’epaule, avec un delai de 1 an pour la normalisation de la fonction de l’epaule.

Purpose The aim of the present study was to describe the precise anatomy of the so-called 'Comma Sign' which has been observed during arthroscopy in retracted subscapularis (SSC) tears. Methods Fourteen fresh cadaveric shoulders were prepared to obtain an articular view comparable to arthroscopic posterior portal view. A step-by-step dissection was carried out to verify the presence of any anatomic structure inserting directly on the lateral margin of the SSC tendon. A sequential detachment of the superior gleno-humeral ligament (SGHL), the coraco-humeral ligament (CHL), and the SSC tendon from their bony humeral insertions was performed. Under intra-articular and extra-articular view, the SSC and its connections with the supraspinatus (SS), the SGHL and the CHL were evaluated. Results The detachment of the CHL and the SGHL from the humerus did not reveal any structure directly inserted on the superior-lateral margin of the SSC tendon. However, when the SSC tendon was excised from the lesser tuberosity and pulled medially, a bundle of fibers, which inserted directly onto its superior-lateral edge, was constantly observed. Conclusions We constantly found an effective link between the superior-lateral corner of the SSC tendon and a bundle of fibers coming from SS and CHL. It became visible only after medial traction of the detached SSC. This structure yields the 'Comma Sign' in subscapularis tendon tears.